One-on-One Mindfulness Training Form
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One-on-One Mindfulness Training 
with Karen Sothers, M.Ed., E-RYT

One-on-One Mindfulness Training Registration Form:

Please complete the following registration form and return to Karen Sothers by clicking on the SEND button at the bottom of this form.  Your information will be transmitted to Karen over an encrypted connection.

Note:  If you navigate away from this page before you click send, your data will be erased and you will need to start over.

Please be assured that Karen will not share your information with anyone else.  If there is information that you are not comfortable recording on this form, you can discuss that information with Karen during your first session.


    To best support you during your One-on-One Mindfulness Training, it is helpful to have a general understanding of your current health conditions, past health history, and significant life events.

    Are you currently engaged with (or have you been in the past) counseling, therapy, psychotherapy or psychiatric care?
    - - If yes, please describe

    Do you have any experience with yoga?
    - - If yes, please describe

    Do you have any experience with meditation or relaxation methods?
    - - If yes, please describe

    Do you have children?

    Do You Smoke? -- If yes, how much

    Sleep quality
    Hours per night

    Do you have challenges with falling asleep?

    Do you have challenges with going back to sleep if you wake up too early?

    Do you consume alcohol?
    - - If yes, Avg. drinks per week

    Personal Goals for One-on-One Mindfulness Training *

    When you are ready to submit your One-on-One Mindfulness Training Form to Karen, please click on the SEND button below and your information will be transmitted over an encrypted connection.

    Note: After clicking SEND below, please wait a moment for confirmation that your message has been sent before you navigate away from this page.